Galen College Of Nursing NUR 155 Exam 3 Study Guide.

Galen College Of Nursing NUR 155 Exam 3 Study Guide. Characteristics of a stage 1 pressure ulcer A nonblanchable area with redness Has minor soft tissue swelling and warmth to area Skin is intact Normally reversible with appropriate nursing care Characteristics of a stage 2 pressure ulcer Partial thickness with loss of skin including the epidermis and or dermis Includes superficial wounds like cuts, blisters, or small open areas Wound is painful Ulcer is seen with reddish pinkish bed without slough or bruising It's superficial and can appear as a blister, or shallow crater Edema persists Can become infected with pain and scant drainage Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:15 Full screen Brainpower Read More Characteristics of a stage 3 pressure ulcer Full thickness skin loss Injury extends through the dermis to the underlying fascia but does not extend through the underlying fascia Not always a deep wound depends on location of wound Wound base is painful Ulcer appears as a deep crater Can have tunneling and undermining but not necessary to be considered a stage 3 Drainage and infection are common Characteristics of a stage 4 pressure ulcer Has full thickness skin loss with visible muscle, tendon , and or bone present Parts may be covered in slough or Eschar Not usually painful due to necrosis Deep pockets of infection may be present Undermining and tunneling are usually present Can be destruction , tissue necrosis , or damage to the muscle , tendon , and bone Unstageable pressure ulcer characteristics When slough or eschar interferes with assessment of depth of pressure injury and therefore staging is not possible Characteristics of a suspected deep tissue injury Skin is intact Patient had a purple or dark red or brown discoloration on the skin Occurs when a pressure injury occurs underneath the skin so depth is unable to be determined Patient may have complained of pain in area before the discoloration occurred The skin may have felt mushy , warm , or cool compared to surrounding areas of skin What are bony prominences? They are the end or a protrusion of bone where skin , muscle, and tissue is thin. They are the highest risk areas of the body for developing pressure sores. Full thickness injury An injury extending through the subcutaneous skin layers, muscles, and down to the bone What is blanching? It's whitening of the skin when pressure is applied. The result is brief temporary loss of blood flow. Note} pressure injuries and ulcers are non-blanchable. What is a Partial thickness injury ? It's an injury to layers of the skin including the subcutaneous, dermis, and , epidermis. Note Partial thickness wounds are associated with stage 2 pressure injuries/ ulcers What is debridement? Within woundcare, debridement refers to the removal of adherent, dead or contaminated tissue from the wound.